TB in children

Question 1

Exposure of TB in Children

Answer 1

(+) History

(-)PPD, CXR, Ssx, Microbiology

Question 2

Different Ssx of TB in children

Answer 2

Chronic cough
Hemoptysis
Weight Loss
Non-specific
Cervical Lymphadenopathy

Question 3

Chest Xray findings in TB

Answer 3

Adult: Cavitary Lesions
Pedia: Hilar lymphadenopathy

Question 4

Typical SSx in adult TB

Answer 4

Chronic cough with hemoptysis
CXR: Upper Lobe Lesions (Apical Gohn’s focus)
Sputum: (+)

Question 5

Typical Ssx in Pedia TB

Answer 5

Non-specific

Difficulty to obtain sputum

Question 6

Typical History of pediatric TB patients

Answer 6

Exposure within householf; howwever informations might be hard to illicit due to stigma

Question 7

PPD

Answer 7

SQ - > 48-72 hours -> induration or erythema

Question 8

Cut Off Measurement for positive effect

Based on Population

Answer 8

Low Endemicity : >5mm

High Endemicity: >10 mm

Question 9

Cut off measurement for positive effect based on risk

Answer 9

High Risk: >5mm

Low risk: >8mm

Question 10

Exposure

Answer 10

(+)Exposure
(-) PPD, CXR, SSx, SPutum

Significant contract with adult

Question 11

Reasons why children is not included as source of infections

Answer 11

Do not have significantly bacillary load
Their cough is not forceful enough
Cavitary disease is rare are not severe

Question 12

_____TB is more common in children

Answer 12

Pacuibacillary TB

-low bacillary load

Question 13

Minimum Distance to be infective

Answer 13

3 ft or 1 meter

Question 14

Management for exposure of TB

Answer 14

<5 years (specially <2 years): Primary prophylaxis

Question 15

INFECTION

Answer 15

(+) Exposure, PPD
(-) CXR, SSX, Sputum

NoteL CXR may be normal or reveal presence of granulomatous or calcifications

Question 16

Group of radiologic/ pathologic findings, not clinical

Answer 16

Primary Complex

Question 17

Most common way of Transmission of TB

Answer 17

Droplet nuclei

Question 18

Immunocompetent adult cut off

Answer 18

15 years old

Question 19

In what years is the greatest risk for progression from infection to disease

Answer 19

2-3 years

Question 20

Treatment of infection

Answer 20

Secondary Prophylaxis

Question 21

T or F, PPD testing is routine for adults?

Answer 21

False

Question 22

Role of PPD in pediatric patients

Answer 22

Know when treatment is most beneficial

Question 23

DISEASE

Answer 23

(+) Exposure, PPD and any of the following

CXR, SSX, or SPutum AFB

Question 24

Criteria for Pedia TB

Answer 24

3 out of 5 (Exposure, PPD, CXR, Ssx, Sputum)

Question 25

Extrapulmonary sites for adults (TB)

Answer 25

15% Lymphatic (25%) Pleura (23%) Meningeal (4%)

Question 26

Extrapulmonary sites for Pedia

Answer 26

25-30% Lymphatic 67% Meningeal 23%

Question 27

2 ways of Transmission for TB

Answer 27

Droplet nuclei | Direct nuclei

Question 28

Children are usually infected by?

Answer 28

Untreated adolescent or adult in the household

Question 29

Interval necessary for source to convert to a smear neagtive state if organisms are fully sensitive

Answer 29

2 weeks

Question 30

Children or adolescent that should be considered as potentially contagious

Answer 30

"symptomatic adult type pTB"

Question 31

Role of child in transmission

Answer 31

harbor latent infection -partially healed but dormant infection can be reactivated as infectious PTB

Question 32

Other portals of entry of entry may be important for the pediatric TB patient

Answer 32

Ingestion - unpasteurized milk Contamination of a supeficial skin infection Congenital infection is rare

Question 33

Perinatal (Congenital) TB can be acquire via:

Answer 33

Transplacental - umbilical vein In utero aspiration of amniotic fluid Ingestion of infected amniotic fluid or secretions

Question 34

Perinatal (Postnatal) TB can be acquired via

Answer 34

Inhalation of tubercle bacilli | Ingestion of infected breast milk or cow's milk

Question 35

Perinatal TB ssx appear during

Answer 35

2 weeks of life: ``` Loss of appetite Failure to gain weight fever ear/nasal discharge cough pneumonia jaundice hepatosplenomegaly ```

Question 36

Lesion on the skin overlying a lymphnode usually in the cervical area

Answer 36

Scrofuloderma

Question 37

Complications usually occur during___

Answer 37

5 years after acquisition of TB infection in childhood | especially the 1st year

Question 38

Complications:

Answer 38

``` Miliary or acute meningeal TB (2-6 months) Endobronchial TB Bone/joint involvement (1 year) Renal Lesions (5-25 years) ```

Question 39

Timetable of tb

Answer 39

Wallgren's timetable

Question 40

Primary Complex

Answer 40

parenchymal pulmonary focus Regional lymph nodes Since about 70% of lung foci are subpleural, localized pleurisy is common

Question 41

Hallmark of primary TB in the lung

Answer 41

Relatively large size of the regional lymphadenitis vs relatively small size of initial lung focus

Question 42

usual sequence in primary TB

Answer 42

hilar lymphadenopathy -> focal hyperinflation -> atelactasis of supplied portion: COLLAPSE-CONSOLIDATION or SEGMENTAL TB

Question 43

Tuberculin skin test

Answer 43

PPD, test for cell mediated immunity againts M.TB

Question 44

Negative results in PPD...

Answer 44

Incubation period (3 weeks to 3 months) Temporary desensitization with measles (regained after 1 month) Influenza and immuniztaion with influenza Sensitization to tuberculin tends to remain undiminished for life (Immune system is working, even if treated -> will detect antigen from now or forever)

Question 45

Considerations: LTBI treatment

Answer 45

1. infants and children < 5 years of age with LTBI have been 2. Risk for progression to disease is high 3. Infants and young children are more likely to have life

Question 46

Optimal dosing of new patients

Answer 46

Daily, but if not possible, weekly

Question 47

Treatment: LTBI

Answer 47

9 month course of INH as self administered daily therapy

Question 48

Treatment of TB in children

Answer 48

WHO: ``` Isoniazid (H) -> 10 mg/kg Max: 300mg/day Rifampicin (R) -> 15mg/kg Max: 600mg/day Pyranazinamide(Z) 35 mg/kg Ethambutol(E) 20mg/kg Streptomycin (S) - IM replaced by ethambutol ```

Question 49

Side effect of ethambutol

Answer 49

optic neuritis

Question 50

Use treatment regimen 2 HRZ 4 HR in the ff:

Answer 50

Children with suspected or confirmed PTB or TB peripheral lymphadenitis Low HIV prevalence or Low resistance to isoniazid Children who are HIV negative

Question 51

Continuation phase of treatment

Answer 51

3x weekly regimens HIV uninfected with well established DOT

Question 52

Treatment for infants (0-3 months) with suspected or confirmed PTB or TB peripheral lymphadenitis

Answer 52

Standard treatment

Question 53

Treatment for children with suspected or confirmed TB menigitis

Answer 53

HRZE 2 HR 10, for a total of 12 months If not penetrative to CNS, 6 month duration

Question 54

Treatment for children with suspected or confirmed osteoarticular TB

Answer 54

HRZE 2 HR 10 for a total of 12 months

Question 55

Treatment for Children with proven or suspected PTB or TB meningitis caused by MDR-TB

Answer 55

fluoroquinolone in the context of a well functioning control program and within an appropriate regimen. Other options: (6-9 mos): bedaquiline, delamanid

Question 56

Treatment modality on Exposure

Answer 56

H x 3 mos + repeat PPD (if positive, extend tx for 9 mo)

Question 57

Treatment modality on Infection

Answer 57

H x 9 months

Question 58

treatment Modality (extent of disease) Pulmonary

Answer 58

HRZ x 2 mo + HR 4 x months | use 3x weekly regimens during continuation phase is as effective as daily regimen

Question 59

treatment modality (extra pulmonary)

Answer 59

6 months - non life threatening forms 9 months - bone and joint 12 months - TB meningitis